Vulnerable Populations and Minors

Vulnerable Populations

• Vulnerable populations need greater protection and have an increased vulnerability to harm.
• Healthcare professionals are guided by laws related to these populations in their decision-making.
• Until the great mass of the people are filled with the sense of responsibility for each other’s welfare, social justice cannot be attained.

Minors

• In the United States, minors are considered anyone under 18 years old.
• Medical procedures for minors generally require parental or guardian consent.
• Policy is shifting towards increased patient autonomy and the rights of patients to be involved in decision-making processes.
• Minors are not considered legally old enough to provide informed consent, so a parent or guardian provides consent.
• Anyone younger than 18 needs someone older to act as a surrogate decision-maker to assume responsibility for doing what is best for the minor.
• The courts will appoint a guardian ad litem if the minor does not have a parent, such as a child whose parents have died or a child in the custody of the state.
• A guardian ad litem acts as the legal guardian for all decision-making processes, including health care decisions.
• Parents may assume the role of guardian ad litem for disabled children after they reach the age of majority or for their elderly parents who are no longer competent.
• Reasonable and rational parents or guardians make healthcare decisions based on family values, resources, and needs.
• Healthcare professionals should explain the various choices available and respect decisions made, regardless of personal opinions.
• Healthcare professionals can provide guidance, but their role is to advise, not judge.
• Religious and cultural differences may influence family decisions regarding medical issues, particularly for minors facing untimely death.
• The Jehovah's Witness religion views blood transfusions as a violation of their religious practice.
• Jehovah's Witnesses believe blood that leaves one body should not be placed in another and should be discarded, however they will accept other fluid infusions.
• Following religious policy is acceptable for informed adults, but withholding a lifesaving procedure from a minor based on parental religious convictions is an ethical and legal dilemma.
• Healthcare professionals may need to consult the legal system when there are conflicts between parental decisions and what the medical community believes is in the child's best interest.
• The case of Johnny illustrates healthcare professionals needing to consult with the legal system when there is a conflict of medical community and decisions of the parents.
• Johnny was diagnosed at 2 yers old, with acute lymphoblastic leukemia.
• Johnny’s parents were practicing Jehovah’s Witnesses who refused all blood transfusions with other therapies.
• Jehovah’s Witness, refuse blood products based on strict observance of certain laws in the Bible.
• However, the hospital obtained a court order to give a blood transfusion if his life was threatened.
• The court was based on the 1944 Supreme Court case of Prince v. Commonwealth of Massachusetts.
• Johnny remained in remission with only one transfusion.
• Parents have the legal right to refuse medical procedures like vaccines for their children, even though healthcare professionals promote vaccinations as beneficial.
• Most states require children to be fully vaccinated before entering public school, but some states allow parents to opt out due to religious or secular convictions.
• The controversy around vaccinations continues, especially as research linking vaccines to developmental disorders has been found fraudulent.
• A measles outbreak in California led to legislation limiting vaccination exemptions to those with medical reasons (SB-277, 2016).
• Courts uphold vaccination requirements for children that are planning to attend a public school.
• A premature infant born at less than 23 weeks' gestation is generally not resuscitated as the medical community agrees the quality of life would be poor.
• After 25 weeks, aggressive measures are taken to resuscitate the newborn.
• The decision for infants born between 23 and 25 weeks is left up to parents and the medical community based on factors like overall health, birth trauma, and family resources.
• Asking parents to provide informed consent at this stage is problematic due to the difficulty of predicting traumatic outcomes.
• Gregory Messenger was accused of manslaughter after he removed his son from a respirator.
• The infant that was born 15 weeks premature the baby had a 50% chance of survival.
• Healthcare professionals may provide guidance on life support decisions, taking into account the reason for life support, such as a tragic accident or chronic illness.
• The ability of minors to make their own healthcare decisions varies by state and depends on factors like the chosen procedures, medical conditions, and privacy laws.
• Typically, most states consider anyone 12 years of age and younger incapable of making informed medical decisions.
• Most states consider anyone 12 years of age and younger incapable of making informed medical decisions, with courts considering various factors once the minor becomes a teenager.
• Many states allow minors to obtain contraceptives and prenatal care without parental consent or notification.
• Title X (10), a federal family planning program, specifically provides these services to minors.
• Attempts to require parental notification or consent for these services have failed.
• Laws in most states require parental consent or notification before a minor can have an abortion.
• The U.S. Supreme Court grants minors limited privacy for abortion procedures, allowing courts to bypass parental consent if the minor is mature enough and understands the risks.
• Other circumstances that allow for a waiver of parental consent for minors include emergency situations where parents would likely consent, sexual abuse cases where the parent is suspected, and mental health or substance abuse services.
• Most states allow anyone over 12 to be tested and treated for STDs, including HIV, without parental notification or consent, though some states require notification or restrict treatment without consent.
• Minors with chronic illnesses are often better suited to make medical decisions due to their experience.
• Factors like stage of development, cognitive and emotional ability, and environment must be considered.
• The mature minor doctrine provides greater autonomy to minors older than 16 who understand and consent to relatively simple medical procedures, which is a legal concept used by the courts and passed as a statute in a few states.
• The legal system can be called upon to intervene if parents and minors disagree on the course of medical action.
• The courts do not always side with a minor.
• Starchild Abraham Cherrix was diagnosed with Hodgkin’s disease where he refused chemotherapy and wanted to proceed with alternative medicine instead.
• The parents were acussed of mistreatment of Starchild Cherrix where.
• The state of Virginia added Abraham’s Law to allow parents to refuse medical treatment or choosse alternative treatments for children age 14-17 with a life-threathening medical condition.
• In some instances, the courts will determine that a teenage patient is not competent to make their own medical decisions.
• Parents or legal guardians will remain the legal decision makers for the minor in these cases.
• Cassandra C was diagnosed with Hodgkin’s Lymphoma, where she refused treatments.
• Cassandra case was reviewed where the state of Connecticut ruled that she was not mature enough, the state took responsibility for Cassandra’s medical care.

Elderly Patients

• Terms such as, healthcare proxy, healthcare agent, healthcare surrogate, and POA for health care are included.
• Advance directives are legal documents outlining health and welfare wishes of a patient if they cannot communicate or are no longer considered competent.
• A do not resuscitate order, or DNR, informs healthcare professionals that patients do not want extreme measures taken to save their life during cardiac arrest.
• A living will is a legal document that indicates whether a patient wants to be placed on life-prolonging machines if they cannot communicate for themselves.
• A power of attorney, or POA, is a written document that legally allows someone to make decisions on another's behalf, with several different types available.
• Advance directives must be created by a competent adult prior to illness or injury.
• This form will direct healthcare professionals in decisions regarding medical care if an elderly patient has an advance directive in their medical record.
• Healthcare professionals might make decisions without an advance directive or family input in emergency situations.
• The medical professionals and family members need to determine what is best for the patient if the patient does not have an advance directive.
• They will most likely use the ethical principle of beneficence (do no harm) in making medical decisions.
• The medical team decides whether certain treatments generally provided to younger patients might cause more harm for elderly patients.
• Competence generally refers to an individual's ability to make decisions necessary to live independently.
• An individual can be declared incompetent, indicating an inability to make necessary decisions, at any age.
• Incompetence in the elderly might be related to diseases such as Alzheimer's or dementia, or simply due to aging or diminished health.
• A family member or healthcare professional may need to appoint a guardian to make medical decisions for the patient.
• Medical professionals should explain options and provide as much information as possible when making decisions to withdraw or withhold medical treatment, especially as these decisions are highly emotional.
• Healthcare professionals should respect family members' choices, even if they disagree and reminders may be needed that cancer is ultimately the cause of death.
• The healthcare professional's job is to serve the patient's best interests, not to make healthcare or other decisions for the patient.
• Healthcare professionals must respect a competent patient's wishes at all times.
• Elderly patients are often faced with increased healthcare expenses.
• Medicare provides healthcare coverage for adults 65 and older, as well as some adults younger than 65 with disabilities.
• Part A helps cover the cost of inpatient care in hospitals, skilled nursing facilities, hospice, and home health care.
• Part A coverage generally comes at no cost to the patient because of prior income tax contributions.
• Medicare provides a monthly premium for those who do not qualify for Part A for free.
• Part B covers other doctor expenses, including some preventive care, medical equipment, and rehabilitation services, usually coming with a monthly premium.
• Parts C and D are optional and provide additional coverage, including prescription drugs.
• The Medicare program is federally funded, but the benefits are provided equally across the nation.
• Medicaid provides assistance to low-income individuals and families to pay for health care.
• The funding for Medicaid comes from the federal government, but the states choose who qualifies and how to distribute the coverage.
• Some states have chosen to expand their Medicaid programs to provide insurance options as required by the Affordable Care Act.
• A physician is not required to accept Medicaid or Medicare, and patients must pay out of pocket or seek another healthcare provider if the physician does not.
• Refusal to accept Medicare or Medicaid patients faces controversy, especially in smaller areas.
• The federal government is allowed to set limits on how much healthcare providers can receive for services provided.
• Healthcare providers feel that the rate of reimbursement is not sufficient and thus choose not to accept patients who use Medicare or Medicaid.
• Additionally, if a facility has been penalized for Medicare or Medicaid fraud, the facility may no longer be allowed to provide services to Medicare and/or Medicaid patients.
• Healthcare facilities strive to avoid Medicare penalties associated with patients who return to the hospital shortly after their original discharge, called a readmission.
• Refusing to serve high-risk patients is another controversial issue where elderly patients rely on Medicare as their primary health insurance.
• Fifteen percent of the United States’ population currently utilizes Medicare for its healthcare needs.
• The estimated number of Medicare beneficiaries is 44 million.
• This number is expected to rise to 79 million by 2030.

HIV/AIDS Patients

• Acquired Immune Deficiency Syndrome (AIDS) are included.
• The polio outbreak resulted in mandatory vaccinations as a necessary way to prevent future outbreaks, as certain communicable diseases cause more public health issues than others.
• The HIV/AIDS epidemic of the 1980’s resulted in certain laws and ethical principles necessary to protect patients with the disease.
• Laws were necessary to ensure that efforts at the testing, prevention, and treatment were not hampered.
• Laws sought to prevent discrimination against individuals living with HIV/AIDS.
• HIV, or human immunodeficiency virus, attacks cells responsible for fighting infection and disease, leaving the patient vulnerable to future diseases and making HIV impossible to fight.
• Over time, HIV infection may lead to AIDS, or acquired immune deficiency syndrome, which is the final stage for HIV patients.
• In this stage, the body can’t naturally fight infections and which leaves patients prone to developing certain cancers.
• HIV is spread through bodily fluids, including blood, semen, breast milk, vaginal fluids, and rectal mucus.
• Urine and fecal Matter contain HIV, however it must be with bodily contact of fluids such as blood in order to to spread.
• HIV is not released without the bodily fluid contact, therefore it is possible to be in contact with HIV patients.
• The total number of people living with HIV in 2016 was 36.7 million.
• Of that total, 34.5 million were adults, 17.8 million were women, 16.7 million were men, and 2.1 million were children under 15 years old.
• There were 1.8 million people newly infected with HIV in 2016, with 1.7 million adults and 160,000 children under 15 years.
• The number of AIDS deaths in 2016 was 1.0 million, with 890,000 adults and 120,000 children.
• HIV is generally transmitted via sexual contact, pregnancy, childbirth, breastfeeding, injected drug use, occupational exposure, blood transfusion, and organ transplant.
• Healthcare professionals are at a greater risk for occupational exposure to HIV because they often exposed to bodily fluids.
• Extra precautions are taken as healthcare professionals such as gloves and masks, can help to avoid communicable diseases.
• Certain laws protect people living with HIV, including the Americans with Disabilities Act (ADA).
• Discrimination based on disabilities is unlawful as, the HIV meets the definition of disability and is covered in the ADA.
• The Health Insurance Portability and Accountability Act (HIPAA) has also helped in the prevention of discrimination against HIV/AIDS patients by keeping their medical condition confidential.
• They limit the ability of insurance companies to exclude patients from coverage if they have a preexisting condition like HIV.
• They prevent group health plans from denying coverage or charging additional fees based on pre-existing conditions, including the family members of people.
• Guarantee certain small-business employers the right to purchase health insurance.
• Employers/individuals are able to purchase health insurance.
• In addition to protection against discrimination, there is federal legislation that attempts to meet the unmet health needs of people living with HIV/AIDS called the Ryan White HIV/AIDS program.
• It is a federal program administered by the Health Resources and Services Administration.
• It focuses on providing funding for healthcare and support services to patients with HIV/AIDS.
• Ryan White was diagnosed with AID’s where the act was later put in place called Ryan White CARE.
• Federal laws are in place to protect patients with HIV/AIDS from discrimination and ensures they receive appropriate treatment.
• Once a patient is diagnosed with HIV, he or she has a legal and ethical responsibility to inform others.

Gender Identity

• Patients with various sexual orientations fall under the category of vulnerable populations.
• Healthcare facilities can not refuse or limit hospital visitation rights of same-sex partners.
• All healthcare facilities should allow patients to designate and not deny visitation privileges on the basis of race, color, national origin, religion, sex, sexual orientation, gender identity, or disability to provide comfort during a stressful time.
• On June 26, 2015, same-sex marriage was legalized in all 50 states, allowing partners the same rights as those who choose to marry in traditional marriage.
• Most medical records only allow patients to identify themselves as one gender which can be difficult for transition patients.
• There's a movement to provide more options in electronic medical records and will take time and adjustment by healthcare professionals.
• Healthcare professionals follow the DEAR (Dignity, Empathy, Autonomy, and Respect) principle, to provide safe and ethical treatment to patients with various gender identities.

Cultural and Other Differences

• Vulnerable populations may be because they weren't sufficiently integrated into the healthcare system due to ethnicity, cultural, economic, geographic, or health characteristics.
• Patients might be reluctant to seek healthcare when it needed due to the language and cultural barriers.
• Access to appropriate healthcare may be limited due to geographic isolation or lack access to appropriate healthcare.
• If healthcare facilities are not aware of the cultural differences they might alienate certain potential patients.
• Some patients find it difficult to obtain insurance coverage because small employers cannot afford to add workers to their health plans who are likely to have high medical costs, and finding an affordable insurance plan as an individual with pre-existing conditions is very difficult.
• Awareness and understanding of vulnerable populations helps toward protecting them and meeting their needs.
• The HELP model can improve patient relations, such as Hear, Encourage, List and Provide.
• To learn more about the cultures, and be respectful when healthcare providers meet diverse patients, but its not always possible for requests to be me.
• Healthcare professionals follow the HELP model, to improve on patient relations, such as Hear, Encourage, List and Provide.

Mandatory Reporting

• Vulnerable populations are often at a greater risk of being abused.
• Healthcare professionals are on the lookout for any signs of neglect or abuse when treating all of their patients.
• Vulnerable populations deserve special attention.
• Mandatory reporting laws require healthcare professionals to report suspected cases of abuse, varying from state to state.
• Healthcare professionals in education, health care, or social work must complete training sessions regarding mandatory reporting.
• Child abuse is physical, sexual, or emotional mistreatment or the neglect of a child.
• Report any questionable injury of children and signs of neglect.
• Report suspected abuse to not be held responsible.
• Follow oral report must be followed by written report.
• Report of suspected child abuse is required from anyone, now matter their occupation.
• Elder abuse includes intentional harm, neglect, exploitation, and abandonment of persons 60 years of age and older.
• Mandatory reporting is more commonly encountered by healthcare professionals in nursing homes or skilled nursing facilities.
• Abusive healthcare workers may be charged with elder abuse.
• Domestic abuse involves willful intimidation, assault, or other abusive behavior committed by one family member or intimate partner against another.
• A healthcare professional is required to report suspected situations to the proper authorities.
• Reporting guidelines vary from state to state but generally include notification of a social worker or supervisor.